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Editor's blog Wednesday 9th December 2009: What happens next. Warning - may contain plot spoilers.

So, what happens next?

(Yes, I've had another interruption. Sick children thing. You know. Anyway, shut up, it's free, innit?)

I think we can start to be clear about quite a few things.

I'm also going to tell you the answer to all the problems the NHS will face during the public sector recession. The answer is, in six roughly equal parts:
The Count from Sesame Street
The Babel Fish from The Hitch-Hiker's Guide To the Galaxy
Indiana Jones
The John Lewis Partnership
The Beatles

There you go. Come back tomorrow and I may even explain it all.

But for the moment, what is going to happen next?

A handbrake turn on contestability
One of the very few brilliant things about being young when I was young was doing handbrake turns. I feel sorry for the youth of today, living in a world of ABS cars and turning off The Sweeney because the clothes are uncool.  You just know they are not going to know how to do a handbrake turn.

Because, my friends, sometimes you just need to go in a direction that physics doesn't want you to go. And that is where the handbrake turn comes in. A bit of skill, a touch of mechanical abuse, a loud screech and there you are - going sideways as gravity fights momentum for control of your destiny.

This policy drift was started by Andy Burnhoid's "NHS preferred provider" speech at the Kings Fund. The dear of DH has left its clarification on this as clear as mud in its guidance: "Where existing NHS services are delivering a good standard of care for patients, there is no need to look to the market ... Where [NHS] primary care trusts are commissioning new services, then we expect them to engage with a range of potential providers before deciding whether to issue an open tender. These decisions will be made locally, and we will not choose to exclude either NHS or private providers on grounds of ideology – quality and what is best for patients must always come first. This could well mean more private provision, not less."

It was confirmed by David Nicholson's recent comments at the DH medical directors' conference about the divesting of PCT provider arms into community FT status. This DH policy goal has turned out to be "nonsense". What is coming is vertical integration, apparently.

David Colin-Thome called PBC a "corpse ... not for resuscitation". It's not clear where that leaves divesting provision and PCts are commissioning-only organisations. But I would say that tinkling sound is the shattering of the policy mosaic.

HSJ has a leak on the NHS becoming responsible for social care, which basically says we're centralising everything. It's effectively nationalisation.

Which is interesting politics, especially looking at the Conservatives' enthusiasm for the Barnet easyCouncil experiments. The military metaphor is spiking their guns, I believe.

From a funding point of view, if the public affection for the NHS is as real as opinion polls tell us, then it might also be contingent economics to bring social care under a funding umbrella that may be more durable than that of local government.

The practical case for closer integration with social care is a no-brainer.

However. The funding arrangements for the NHS's new subsidiary, the National Care Service, remain profoundly unclear and the figures to date have been comedy. Our darling Chancellor Darling's pre-budget report has pointed out in a low-key way that there is going to be very little extra money for anyone anywhere to play with - and I hope you noted the phrasing about " guaranteed minimum real terms increases in spending on frontline NHS and schools for two years from 2011 ... I can confirm not just that we will increase spending as planned next year, in hospitals, schools and policing" - lots of wriggle room there in the choice of the word "hospital").

So I don't think means-testing will be going away - not for the tiny sums in question so far. It is just possible that the politicians are not going to tell us the truth about the costs of a National Care Service.

Vertical integration and the National Hospital Service
So. Alan Maynard's predictions of recent years have been proven right: there is going to be some sort of split tariff. That'll put the 'oof' into the Operating Framework. Particularly if FTs start running primary care.

If I were an independent contractor GP, I would be extremely worried about where some of this was going. But then, maybe I'd be reassured by a strong sense that the BMA was writing the DH's policy, given its recent manifesto, Standing up for Doctors - Standing up for Health.

The data day
Darling Darling also eschewed the opportunity in his PBR today to make a high-profile announcement with which he should be personally associated about NHS IT. But he'd used the far more political arena of the BBC1 Andrew Marr Show on Sunday morning to give the Thumb Of Doom to NHS Connecting For Health, saying it is “not essential to the frontline” and that it might be something “we do not need to go ahead with right now.”

However, the emerging picture about what this actually means is quite different - a tiny haircut of £600 million on CfH's £12.7 billion programme budget (£4.5 billion of which was spent as of April 09).

Now, as the furore over Dr Fosters' latest guide has shown, data is an important and potent tool.  However, once you start unwinding the contestability agenda (presumably paying the various 'Big Four' management consultancies huge sums to show you how), then you run the risk of de-emphasising commissioning - especially if you are going to have all provision led by the acute sector. FT status gives the 'senior service' intrinsic incentives to maximise their revenue. productivity = activity.

The operating framework could be going incentive-crazy. I'm hearing about perky inflation in PROMs and in fines relating to CQUIN and 'never' events (wrong-site surgery et al). So no money at all to be made for the lawyers there, then. Nor any risk of the information being used to run before it can walk, and so magnifying mutual distrust between clinicians and managers.

Musical chairs
I have no idea whether Bill Moyes or Barbara Young are musical people. I kind of hope they are, as both of them seem like okay, paid-up members of the human race.

However, their respective imminent and current absences from the chairs of their organisations reverberates resonantly.

We have done Bill Moyes' exit on here before, and have arranged an interview with him in January, which should be good fun. Barbara Young I know only by reputation, but like the excellent Peter Homa, she has chosen to jump ship from a dysfunctional regulator. It's not the CQC's fault that the Healthcare Commissions legacy was so problematic.

Cah. Whatever happened to Ian Kennedy, eh?

But it's a real problem for Monitor, whose executive chair (Moyes' title) is its senior accountable officer. Rumour has it that the field of candidates was seriously unimpressive.

There is some of it. I may have some more tomorrow, time permitting.

Handbrake policy turns. Fasten your seatbelts, and check that your insurance policy is in order.